II. Epidemiology

III. Associated Conditions

  1. Results in sun-downing
    1. Risk of falls
    2. Wandering Behavior in Dementia
  2. Family exhausted by required nighttime supervision
    1. Strong factor in NH placement

IV. Pathophysiology

  1. Normal sleep changes in all elderly
    1. Decrease in delta sleep
    2. Increased nocturnal awakenings
  2. Additional sleep changes in Dementia
    1. Decreased circadian cycle length
    2. Sleep cycle disconnected from environs and Time cues

V. Management: Behavioral techniques

  1. Aggressive management necessary
  2. Increase awareness of time
    1. Frequent reality orientation
    2. Access to daylight
  3. General Sleep Hygiene
    1. Restrict Caffeine and Stimulant Medications
    2. Restrict daytime naps
    3. Perform moderate Exercise early in the day
    4. Keep room cool and quiet
  4. Provide safe night-time environment
    1. Night light reduces confusion if patient awakens
  5. Reduce nighttime awakenings and potential wandering
    1. Provide nighttime Analgesic for arthritic pain
    2. Reduce Urinary urge and wetness at night
      1. Limit evening fluid intake
      2. Provide bedside commode
      3. Consider Condom catheter
      4. Use Incontinence garment
      5. Apply moisture barrier (Vaseline) to perineum

VI. Management: Medications

  1. Indications
    1. Failed response to behavioral techniques
  2. Preferred options
    1. Antipsychotic Medications (not FDA approved for Insomnia)
      1. Zyprexa 2.5 to 5 mg orally taken 1 hour before bedtime
      2. Seroquel 25 mg orally taken 1 hour before bedtime
    2. Antidepressants (especially for comorbid depression or need to stimulate appetite)
      1. Remeron 15 mg orally taken before bedtime
    3. Melatonin agents
      1. Rozerum 8 mg
  3. Other agents
    1. Trazodone 50 mg PO qhs
  4. Older preparations (listed for historical purposes)
    1. Chloral Hydrate 500-1000 mg PO qhs
    2. Thioridazine 25-50 mg PO qhs
  5. Adverse effects
    1. Ataxia with fall risk
    2. May worsen confusion due to Anticholinergic effects
  6. Avoid agents that worsen confusion
    1. Avoid Benzodiazepines
    2. Avoid Anticholinergic Medications
      1. Avoid Atarax (Vistaril) and Benadryl
      2. Avoid Tylenol PM

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